Environmental risk factors for multiple sclerosis. Part II: Noninfectious factors

The association between vitamin D deficiency and multiple sclerosis: an updated systematic review and meta-analysis

BACKGROUND

Although there is evidence of a link between vitamin D status and risk of multiple sclerosis (MS), there has been no systematic review where the exposure measure was vitamin D deficiency rather than 25 hydroxy vitamin D (25(OH)D) concentration. We conducted an updated systematic review and meta-analysis to estimate the association between vitamin D deficiency, defined in most studies as a serum 25(OH)D concentration of < 50 nmol L-1, and MS.

METHODS

We searched the MEDLINE, EMBASE, and CINAHL databases to identify relevant publications. We estimated the pooled odds ratio (OR) using a random effects model for the association between vitamin D deficiency and MS, overall and stratified by several factors, including whether or not studies included participants who were taking vitamin D supplements. We also analysed the association between mean 25(OH)D concentration and MS, and used meta-regression to assess the effects of vitamin D supplementation, latitude, age, ethnicity, vitamin D definition and seasonality on the OR estimates. The Newcastle-Ottawa Scale was used to assess study quality.

RESULTS

Results were pooled across 14 case-control studies published between 2007 and 2021 (n = 4130 cases, n = 4604 controls). Persons with vitamin D deficiency had a 54 % higher risk of multiple sclerosis than those with sufficient vitamin D status (OR 1.54; 95 % CI 1.05, 2.24). In studies that excluded participants taking vitamin D supplements (N = 7), the OR was 2.19 (95 % CI: 1.44, 3.35), whereas, in studies that did not exclude participants taking supplements, there was no increase in risk (OR 0.82; 95 % CI: 0.43, 1.58). Mean age (R2 = 27.4 %) and inclusion/exclusion of participants taking supplements (R2 = 33.4 %) contributed most to variability in the OR of vitamin D deficiency and MS.

CONCLUSION

Vitamin D deficiency is associated with an increased likelihood of multiple sclerosis. Maintaining sufficient vitamin D may be an important modifiable risk factor for MS.

Environmental factors related to multiple sclerosis progression

Multiple Sclerosis (MS) is a complex neurological disease which prevalence is increasing worldwide. The impact of environmental factors on MS susceptibility has already been defined and highlighted in many previous reports, particularly vitamin D or ultraviolet B light exposure, Epstein-Barr virus (EBV) infection, obesity, and smoking. There is increasing evidence that environmental and lifestyle factors are not only important in triggering MS but are also implicated in MS progression. Low sun exposure and vitamin D deficiency exhibit a strong relationship with disease progression in both animal and human studies. The gestational period seems also to impact long-term disease progression as January's babies had a higher risk of requiring walking assistance than those born in other months. The implication of EBV in neurodegeneration and MS progression was also suggested even though its specific targets and mechanisms are still unclear. Cigarette smoking is correlated with faster clinical progression. The association of obesity and smoking seems to be associated with a faster progression and an increased rate of brain atrophy. Although the effect of air pollution on MS pathogenesis remains not fully understood, exposure to polluted air can stimulate several mechanisms that might contribute to MS severity. People with MS with active disease have an altered microbiota compared to patients in the remission phase. Cardiovascular comorbidities, epilepsy, and depression are also associated with a more severe disability accrual. Knowledge about MS modifiable risk factors of progression need to be incorporated into everyday clinical practice in order to ameliorate disease outcomes.

Distinct plasma lipids predict axonal injury and multiple sclerosis activity

BACKGROUND

Lipids are of particular interest for the study of neuroinjury and neuroinflammation as structural lipids are major components of myelin, and a variety of lipid species modulate inflammation. In this study, we performed an in-depth lipidomics analysis to identify lipids associated with injury and disease activity.

METHODS

Plasma samples were collected from paediatric-onset multiple sclerosis (MS) cases within 4 years of disease onset from 17 sites. The lipidome was measured using untargeted and targeted mass spectrometry. For cross-sectional analyses, the agreement between multiple machine learning models was used to predict neurofilament light chain (NfL) levels. In longitudinal analyses, the association between clinical (relapse count) and imaging (MRI count with ≥1 enhancing or new T2 lesion) outcomes with each metabolite was estimated using adjusted negative binomial regression.

RESULTS

At sample collection, 68% of the 435 included individuals were treatment-naive, with a median disease duration of 0.8 years (IQR 0.3-1.7). For longitudinal analyses, 381 and 335 subjects had at least 1 year of clinical and imaging follow-up, respectively. In cross-sectional analyses, NfL chain levels identified structural lipids (phosphatidylcholines and phosphatidylethanolamines) as the highest-performing predictors, including external validation. In contrast, longitudinal analyses found polyunsaturated fatty acids (PUFAs) and their derivatives to be protective from subsequent disease activity (q<0.001, multiple outcomes).

CONCLUSION

There are two categories of lipids associated with MS processes. First, structural lipids strongly associated with NfL levels may result from cell lysis secondary to acute inflammation. In contrast, PUFAs, especially ω-3, had a protective effect on subsequent disease activity.

Trends in mortality due to multiple sclerosis in the United States: A retrospective analysis from 1999 to 2020

BACKGROUND

Multiple sclerosis (MS) is a neuroinflammatory condition with a prevalence of about 309.2 per 100,000 people in the United States. We aim to identify MS-related mortality trends in the USA from 1999 to 2020, stratified by age, sex, race, and geography, and its correlation with sunlight.

METHODS

Death certificates from the CDC-WONDER database were examined for adults aged ≥25 years. Crude rates (CR) and age-adjusted mortality rates (AAMRs) per 1,000,000 persons and annual percent change (APC) were calculated. We also retrieved data for daily sunlight from 1999 to 2011.

RESULTS

From 1999 to 2020, a total of 121,694 deaths occurred due to MS. The AAMR rose from 23.6 in 1999 to 29.7 in 2020 (APC 0.65), with a stable trend till 2018 (APC -0.22) followed by an abrupt increase towards 2020 (APC 9.27). Women had higher AAMR than men. Non-Hispanic (NH) Whites exhibited the highest AAMR (28.5), followed by NH Blacks (25.9), NH American Indians/Alaska Natives (9.6), Hispanics or Latino (6.8), and NH Asian or Pacific Islanders (1.9). AAMRs also varied substantially by region (Midwest: 32.4; Northeast: 26.9; West: 26.2; South: 19.4). States with the highest AAMRs were Montana, Wyoming, Colorado, and Oregon. The states with lower daily sunlight had higher AAMRs (r = -0.559, p = 0.000). AAMRs were comparable in urban (25) and rural (26.3) areas. Most deaths occurred in medical facilities (33.92 %) and nursing homes / long-term care (30.80 %), followed by home (27.79 %), and hospice (4.06 %). Adults ≥ 65 years depicted the highest mortality rates (CR 64.4) while adults aged 25 to 44 years showed the lowest rates (CR 4.6).

CONCLUSION

We found an overall stable trend in MS-related mortality rates in the US till 2018 with a sharp increase thereafter. We observed highest mortality among women and NH White adults, among residents of Midwest and Northeast regions, and among adults ≥ 65 years. Higher disease burden in recent years calls for devising timely policies focused on these high-risk populations.

Wilson's Disease-Crossroads of Genetics, Inflammation and Immunity/Autoimmunity: Clinical and Molecular Issues

Wilson's disease (WD) is a rare, autosomal recessive disorder of copper metabolism caused by pathogenic mutations in the ATP7B gene. Cellular copper overload is associated with impaired iron metabolism. Oxidative stress, cuproptosis, and ferroptosis are involved in cell death in WD. The clinical picture of WD is variable. Hepatic/neuropsychiatric/other symptoms may manifest in childhood/adulthood and even old age. It has been shown that phenotypic variability may be determined by the type of ATP7B genetic variants as well as the influence of various genetic/epigenetic, environmental, and lifestyle modifiers. In 1976, immunological abnormalities were first described in patients with WD. These included an increase in IgG and IgM levels and a decrease in the percentage of T lymphocytes, as well as a weakening of their bactericidal effect. Over the following years, it was shown that there is a bidirectional relationship between copper and inflammation. Changes in serum cytokine concentrations and the relationship between cytokine gene variants and the clinical course of the disease have been described in WD patients, as well as in animal models of this disease. Data have also been published on the occurrence of antinuclear antibodies (ANAs), antineutrophil cytoplasmic antibodies (ANCAs), anti-muscle-specific tyrosine kinase antibodies, and anti-acetylcholine receptor antibodies, as well as various autoimmune diseases, including systemic lupus erythematosus (SLE), myasthenic syndrome, ulcerative colitis, multiple sclerosis (MS), polyarthritis, and psoriasis after treatment with d-penicillamine (DPA). The occurrence of autoantibodies was also described, the presence of which was not related to the type of treatment or the form of the disease (hepatic vs. neuropsychiatric). The mechanisms responsible for the occurrence of autoantibodies in patients with WD are not known. It has also not been clarified whether they have clinical significance. In some patients, WD was differentiated or coexisted with an autoimmune disease, including autoimmune hepatitis or multiple sclerosis. Various molecular mechanisms may be responsible for immunological abnormalities and/or the inflammatory processes in WD. Their better understanding may be important for explaining the reasons for the diversity of symptoms and the varied course and response to therapy, as well as for the development of new treatment regimens for WD.

Fruits and vegetables intake may be associated with a reduced odds of multiple sclerosis: a systematic review and dose-response meta-analysis of observational studies

INTRODUCTION

Multiple sclerosis (MS) is an immune-mediated condition of the central nervous system (CNS). Intake of fruits and vegetables high in vitamins, minerals, fiber, and active molecules contributes to the body's overall health, immunity, and physiological function. This study sought to review the literature and investigate the relationship between fruits and vegetables consumption and MS odds.

METHODS

In the current systematic review and meta-analysis, a systematic search of original databases from inception to 21 Dec 2022 was conducted based on the PRISMA 2020 statement. Human observational studies examining the association between fruits or vegetables consumption and MS prevalence were included if they reported and provided effect size with 95% confidence intervals (CIs).

RESULTS

The systematic review and meta-analysis included eight studies. Random effect model showed the protective effect of fruits (I2 = 81.0%, P for heterogeneity < 0.001; pooled OR = 0.52, 95%CI = 0.27, 0.97, P-value = 0.042) and vegetables consumption (I2 = 73.5%, P for heterogeneity = 0.002; pooled OR = 0.61, 95%CI = 0.38, 1.00, P-value = 0.050) on MS odds. According to a linear dose-response meta-analysis of four case-control studies, an increase of 100 grams of fruits per day reduced the odds of MS by 9% (I2 = 0.0%, P for heterogeneity = 0.77; pooled OR = 0.91, 95%CI = 0.83, 0.99, P-value = 0.021).

CONCLUSION

Consumption of fruits and vegetables may be associated with a potential protective effect against MS. However, further confirmation is required through prospective longitudinal studies and randomized clinical trials.

Neurofilaments in neurologic disease

Neurofilaments (NFs), major cytoskeletal constituents of neurons, have emerged as universal biomarkers of neuronal injury. Neuroaxonal damage underlies permanent disability in various neurological conditions. It is crucial to accurately quantify and longitudinally monitor this damage to evaluate disease progression, evaluate treatment effectiveness, contribute to novel treatment development, and offer prognostic insights. Neurofilaments show promise for this purpose, as their levels increase with neuroaxonal damage in both cerebrospinal fluid and blood, independent of specific causal pathways. New assays with high sensitivity allow reliable measurement of neurofilaments in body fluids and open avenues to investigate their role in neurological disorders. This book chapter will delve into the evolving landscape of neurofilaments, starting with their structure and cellular functions within neurons. It will then provide a comprehensive overview of their broad clinical value as biomarkers in diseases affecting the central or peripheral nervous system.

Usefulness of bioelectrical impedance analysis in multiple sclerosis patients-the interrelationship to the body mass index

Background

Patients with multiple sclerosis (MS) have many potential factors (disease duration, spasticity, immobilization, or glucocorticoid use) that can deteriorate their nutritional status and impact both the progression and prognosis of the disease. Body mass index (BMI), the most widely used nutritional status assessment tool, has important limitations because it does not provide any data on body composition.

Aim

This study aimed to assess the interrelationship between nutritional status assessment by both body mass index (BMI) and body composition using bioelectrical impedance analysis (BIA) and the consistency of diagnosis for underweight/underfat, normal weight/healthy, overweight/overfat, and obesity/obese MS patients.

Methods

Anthropometric [BMI and waist-to-height ratio (WHtR)] and body composition (BIA) data were evaluated in 176 patients with MS. Patients were categorized into four nutritional status subgroups (underweight, normal weight, overweight, obese according to BMI, and underfat, healthy, overfat, and obese according to fat mass% by BIA). The median Expanded Disability Status Scale score was 4.5. Patients were then divided according to EDSS score as mild (EDSS 1.0-4.0) or moderate (EDSS 4.5-6.5) disability subgroups.

Results

Based on BIA assessment, there was a significantly higher prevalence of overfat than of overweight based on BMI [n = 50 (28.41%) vs. n = 38 (21.59%); p < 0.05]. However, the prevalence of obesity did not differ significantly regardless of the mode of diagnosis and was not significantly lower when assessed using BIA [n = 26 (14.77%) vs. n = 30 (17.05%), respectively]. The overall compatibility rates (CR) of diagnoses made using both BMI and BIA were 75.6, 77.0, and 70.1% for all patients with MS and the mild and moderate subgroups, respectively. The lowest CR was observed in the overweight group. Adiposity significantly underestimated BMI in all subgroups. In the moderate MS subgroup, BMI significantly overcategorized patients with MS as having a normal weight (p < 0.05). Stratification for abdominal obesity (WHtR > 0.5) showed that BMI significantly underestimated the prevalence of MS in overweight and obese vs. overfat and obese patients, as assessed using BIA (60.5 vs. 67%; p < 0.05). Clinical status (EDSS and ΔEDSS) was more closely related to the nutritional status categorized by FAT% assessed using BIA than using BMI cutoff points. However, the relationship was not statistically significant.

Conclusion

Using the BMI cutoff point for nutritional status assessment in patients with MS is associated with a significant underestimation of excess fat mass. BIA-based FAT% based on BIA have a better relationship with abdominal obesity and disability status than with BMI in patients with MS. The highest rate of false-negative diagnoses was based on the BMI in patients with MS and moderate disability. Adiposity assessment using BIA appears to be a useful method for proper nutritional status assessment in the patients group.

The Role of Diet in Multiple Sclerosis Onset: A Prospective Study Using UK Biobank

Multiple sclerosis (MS) is a debilitating autoimmune condition primarily affecting young adults, and its rise is evident globally. Despite this, its precise etiology remains elusive. Both genetic and environmental factors contribute to MS susceptibility; however, the link between diet and MS lacks substantial evidence due to limited large-scale studies. We exploited the UK Biobank resources to explore the nexus between diet, lifestyle, and MS risk. The dietary and lifestyle habits of MS incident cases, derived from a general food frequency questionnaire (FFQ) completed by all participants at study enrollment, were compared to those of subjects who did not develop MS during the follow-up. Our findings suggest the protective role of moderate oily fish consumption and weekly alcohol intake. Furthermore, by analyzing food intake data obtained through 24 h recall, completed by a subset of participants, we found a protective, though non-significant, trend of an increased adherence to the Mediterranean diet (MD). These findings, derived from the analysis of the UK Biobank and representing an unprecedented approach for this inquiry, warrant further exploration and integration in future research.

Short-chain fatty acid producers in the gut are associated with pediatric multiple sclerosis onset

OBJECTIVE

The relationship between multiple sclerosis and the gut microbiome has been supported by animal models in which commensal microbes are required for the development of experimental autoimmune encephalomyelitis. However, observational study findings in humans have only occasionally converged when comparing multiple sclerosis cases and controls which may in part reflect confounding by comorbidities and disease duration. The study of microbiome in pediatric-onset multiple sclerosis offers unique opportunities as it is closer to biological disease onset and minimizes confounding by comorbidities and environmental exposures.

METHODS

A multicenter case-control study in which 35 pediatric-onset multiple sclerosis cases were 1:1 matched to healthy controls on age, sex, self-reported race, ethnicity, and recruiting site. Linear mixed effects models, weighted correlation network analyses, and PICRUSt2 were used to identify microbial co-occurrence networks and for predicting functional abundances based on marker gene sequences.

RESULTS

Two microbial co-occurrence networks (one reaching significance after adjustment for multiple comparisons; q < 0.2) were identified, suggesting interdependent bacterial taxa that exhibited association with disease status. Both networks indicated a potentially protective effect of higher relative abundance of bacteria observed in these clusters. Functional predictions from the significant network suggested a contribution of short-chain fatty acid producers through anaerobic fermentation pathways in healthy controls. Consistent family-level findings from an independent Canadian-US study (19 case/control pairs) included Ruminococaccaeae and Lachnospiraceae (p < 0.05). Macronutrient intake was not significantly different between cases and controls, minimizing the potential for dietary confounding.

INTERPRETATION

Our results suggest that short-chain fatty acid producers may be important contributors to multiple sclerosis onset.

Multiple sclerosis prevalence and its relationship with economic status in Afyonkarahisar, Turkey

BACKGROUND

Over the past decade, the prevalence of Multiple Sclerosis (MS) has increased in Turkey. However, the prevalence of MS in Middle Anatolia, specifically Afyonkarahisar, remains unknown. Additionally, the potential link between economic status and MS has not yet been explored in Turkey.

METHODS

A stratified sampling method was employed to select samples from the population residing in Afyonkarahisar City Center, taking into account demographic factors such as income level, sex, and age. The sample size was calculated using the formula N = p.q.Zα2/d2, where an average prevalence rate of 70/100,000 was considered based on previous studies. The minimum sample size was 29,858. Considering incomplete, inaccurate, and low-reliability data, data were collected from 30,500 individuals and 30,408 individuals were evaluated.

RESULTS

The prevalence of Multiple Sclerosis in the center of Afyonkarahisar was 105.2 per 100,000 individuals. Upon investigating the association between economic status and MS prevalence, the findings revealed rates of 193.6 per 100,000 in individuals with high income, contrasting with 80.2 per 100,000 in those with low income. Notably, a heightened prevalence of MS is evident among individuals with higher income levels.

CONCLUSION

This study revealed a significantly elevated prevalence of MS in Afyonkarahisar, the highest in Turkey. The inverse correlation between the prevalence of MS and socioeconomic status is intriguing. Possible reasons for the high prevalence include the relatively new and specific geologic and environmental conditions in the area.

Reactive nitrogen species as therapeutic targets for autophagy/mitophagy modulation to relieve neurodegeneration in multiple sclerosis: Potential application for drug discovery

Multiple sclerosis (MS) is a neuroinflammatory disease with limited therapeutic effects, eventually developing into handicap. Seeking novel therapeutic strategies for MS is timely important. Active autophagy/mitophagy could mediate neurodegeneration, while its roles in MS remain controversial. To elucidate the exact roles of autophagy/mitophagy and reveal its in-depth regulatory mechanisms, we conduct a systematic literature study and analyze the factors that might be responsible for divergent results obtained. The dynamic change levels of autophagy/mitophagy appear to be a determining factor for final neuron fate during MS pathology. Excessive neuronal autophagy/mitophagy contributes to neurodegeneration after disease onset at the active MS phase. Reactive nitrogen species (RNS) serve as key regulators for redox-related modifications and participate in autophagy/mitophagy modulation in MS. Nitric oxide (•NO) and peroxynitrite (ONOO-), two representative RNS, could nitrate or nitrosate Drp1/parkin/PINK1 pathway, activating excessive mitophagy and aggravating neuronal injury. Targeting RNS-mediated excessive autophagy/mitophagy could be a promising strategy for developing novel anti-MS drugs. In this review, we highlight the important roles of RNS-mediated autophagy/mitophagy in neuronal injury and review the potential therapeutic compounds with the bioactivities of inhibiting RNS-mediated autophagy/mitophagy activation and attenuating MS progression. Overall, we conclude that reactive nitrogen species could be promising therapeutic targets to regulate autophagy/mitophagy for multiple sclerosis treatment.

Computational analysis of five neurodegenerative diseases reveals shared and specific genetic loci

Neurodegenerative diseases (ND) are heterogeneous disorders of the central nervous system that share a chronic and selective process of neuronal cell death. A computational approach to investigate shared genetic and specific loci was applied to 5 different ND: Amyotrophic lateral sclerosis (ALS), Alzheimer's disease (AD), Parkinson's disease (PD), Multiple sclerosis (MS), and Lewy body dementia (LBD). The datasets were analyzed separately, and then we compared the obtained results. For this purpose, we applied a genetic correlation analysis to genome-wide association datasets and revealed different genetic correlations with several human traits and diseases. In addition, a clumping analysis was carried out to identify SNPs genetically associated with each disease. We found 27 SNPs in AD, 6 SNPs in ALS, 10 SNPs in PD, 17 SNPs in MS, and 3 SNPs in LBD. Most of them are located in non-coding regions, with the exception of 5 SNPs on which a protein structure and stability prediction was performed to verify their impact on disease. Furthermore, an analysis of the differentially expressed miRNAs of the 5 examined pathologies was performed to reveal regulatory mechanisms that could involve genes associated with selected SNPs. In conclusion, the results obtained constitute an important step toward the discovery of diagnostic biomarkers and a better understanding of the diseases.

Relationship of tryptophan metabolites with the type and severity of multiple sclerosis

BACKGROUND

Tryptophan is an essential amino acid primarily metabolized by the kynurenine pathway in mammals. Intermediate metabolites emerging in this pathway have been associated with many neurogenerative diseases. This study aimed to compare tryptophan pathway metabolite levels in patients with multiple sclerosis (MS) and healthy controls and reveal the relationship of tryptophan metabolites with disease subtype and the Expanded Disability Status Scale (EDSS) score.

METHODS

The study included a total of 80 MS cases [53 with relapsing remitting MS (RRMS) and 27 with secondary progressive MS (SPMS)] and 41 healthy volunteers. The patients with RRMS were further divided into relapse (RRMS-attack) and non-attack (RRMS-stable) groups. Using liquid chromatography mass spectrometry, tryptophan, kynurenine, kynurenic acid, quinolinic acid, 3-hydroxykynurenine, and 3-hydroxyanthranilic acid levels were measured. The serum metabolite levels of the patient and control groups were compared. In addition, the link and relationship between the EDSS score and disease duration of the patients and their plasma tryptophan metabolite levels were examined.

RESULTS

The tryptophan level of the patient group was significantly lower than that of the healthy controls (p<0.05). The kynurenine (105.38±65.43), quinolinic acid (10.42±3.56), kynurenine/tryptophan ratio (0.0218±0.019), and quinolinic acid/kynurenic acid ratio (1.7054±0.96141) of the patients with MS were significantly higher compared to the controls (p<0.05). In the receiver operating characteristic analysis of the power of kynurenine/tryptophan and quinolinic acid/kynurenic acid ratios in predicting the disease, both ratios predicted the diagnosis of MS (area under the curve: 0.793 and 0.645, respectively; p<0.05), albeit at low sensitivity and specificity. The parameters were similar between the RRMS-attack and RRMS-stable patient groups (p>0.05). There was also no significant difference between the RRMS and SPMS patient groups in terms of tryptophan metabolites (p>0.05). Lastly, no significant relationship was observed between tryptophan metabolites and MS subtype and the EDSS score.

CONCLUSION

Our findings revealed that the kynurenine pathway involved in the tryptophan metabolism differed between the patients with MS and healthy controls, and this difference may be a limited guide in the diagnosis of MS, due to major overlaps in values for MS versus Controls, and is insufficient to determine the disease subtype.

A review on plant-based remedies for the treatment of multiple sclerosis

Multiple sclerosis (MS) is a complex autoimmune disease of central nervous system, which is degenerative in nature usually appears between 20-40years of age. The exact cause of MS is still not clearly known. Loss of myelin sheath and axonal damage are the main features of MS that causes induction of inflammatory process and blocks free conduction of impulses. Till date FDA has approved 18 drugs to treat or modify MS symptoms. These medicines are disease-modifying in nature directed to prevent relapses or slow down the progression of disease. The use of the synthetic drug over an extended period causes undesirable effects that prompt us to look at Mother Nature. Complementary and alternative medicine involves the use of medicinal plants as an alternative to the existing modern medical treatment. However, modern drugs cannot be replaced completely with medicinal plants, but the two types of drugs can be used harmoniously with later one can be added as an adjuvant to the existing treatment. These medicinal plants have the potential to prevent progression and improve the symptoms of MS. Various plants such like Nigella sativa, ginger, saffron, pomegranate, curcumin, resveratrol, ginsenoside have been tested as therapeutics for many neurodegenerative diseases. The purpose of this write-up is to make information available about medicinal plants in their potential to treat or modify the symptoms of MS. Chronically ill patients tend to seek medicinal plants as they are easily available and there is a general perception about these medicines of having fewer undesirable effects.

Dietary patterns and risk of multiple sclerosis: Results of a double-center case-control study in Iran

Background: It has been suggested that nutrition might contribute to multiple sclerosis etiology (MS). Aim: This case-control study aimed to determine the role of food habits and dietary patterns in preventing or developing MS in a multicenter study in Iran (Tehran and Shiraz). Methods: In this study, food intake of (106 patients with relapsing/remitting MS (RRMS) and 72 healthy controls in Tehran) and (75 patients with relapsing/remitting MS (RRMS) and 72 healthy controls in Shiraz) were collected using a validated semi-quantitative food frequency questionnaire. Dietary patterns were extracted using factor analysis. The association between dietary patterns and the risk of MS was analyzed by Logistic regression. Results: Two major dietary patterns were extracted: the "healthy" and the "unhealthy" patterns. After adjustment for potential confounders, in Tehran city, subjects in the highest tertile of the unhealthy dietary pattern score had greater odds of having MS, compared with those in the lowest tertile (OR: 2.16; 95% CI: [1.95-2.41]; p for trend  =  0.01). In Shiraz city, subjects in the highest tertile of the unhealthy dietary pattern score had greater odds with MS than those in the lowest tertile (OR: 3.08; 95% CI: [1.27-7.38]; p for trend  =  0.01). However, in both groups, no significant association was found between healthy dietary pattern and MS risk. Conclusions: Adherence to unhealthy dietary pattern may increase the risk of MS in Iran. The results can be used for developing interventions that aim to promote healthy eating for preventing MS.

Advanced brain MRI may help understand the link between migraine and multiple sclerosis

BACKGROUND

There is a clinical association between migraine and multiple sclerosis.

MAIN BODY

Migraine and MS patients share similar demographics, with the highest incidence among young, female and otherwise healthy patients. The same hormonal constellations/changes trigger disease exacerbation in both entities. Migraine prevalence is increased in MS patients, which is further enhanced by disease-modifying treatment. Clinical data show that onset of migraine typically starts years before the clinical diagnosis of MS, suggesting that there is either a unidirectional relationship with migraine predisposing to MS, and/or a "shared factor" underlying both conditions. Brain imaging studies show white matter lesions in both MS and migraine patients. Neuroinflammatory mechanisms likely play a key role, at least as a shared downstream pathway. In this review article, we provide an overview of the literature about 1) the clinical association between migraine and MS as well as 2) brain MRI studies that help us better understand the mechanistic relationship between both diseases with implications on their underlying pathophysiology.

CONCLUSION

Studies suggest a migraine history predisposes patients to develop MS. Advanced brain MR imaging may shed light on shared and distinct features, while helping us better understand mechanisms underlying both disease entities.

Predictive value of α-synuclein expression in peripheral blood of multiple sclerosis patients: A two-dimensional assessment of a selected biomarker

INTRODUCTION

Our study aimed to evaluate whether assessing α-synuclein expression levels in blood samples could provide a reliable and straightforward alternative to existing diagnostic and prognostic methods for neurodegenerative disorders, including multiple sclerosis (MS). We specifically investigated if α-synuclein and IL-6 expression levels from serum and peripheral blood mononuclear cells (PBMCs) could accurately predict MS severity in patients using a two-dimensional approach.

METHODS

We designed a case-control study to analyze the expression of α-synuclein and IL-6 in the peripheral blood of an MS patient group (n = 51) and a control group (n = 51). We statistically evaluated the PBMCs and serum profiles of α-synuclein and IL-6 in MS patients, along with their age of onset, disease duration, tobacco exposure, and Expanded Disability Status Scale (EDSS) score, using SPSS V22.0 software and GraphPad Prism V9.0.

RESULTS

Our findings indicate that α-synuclein production was significantly downregulated in MS patients. Principal component analysis also revealed distinct profiles between MS patients and controls. PBMCs and serum profiles of α-synuclein correlated with the EDSS score, suggesting that disease severity can be predicted using α-synuclein profiles. Moreover, α-synuclein showed a significant correlation with IL-6 and age of onset. Lastly, receiver operating characteristic curves of PBMCs and serum activity of α-synuclein profiles displayed discrimination with area under the curve values of 0.856 and 0.705, respectively.

CONCLUSION

Our results imply that measuring α-synuclein levels in both serum and PBMCs could be a valuable method for diagnosing and predicting MS severity, potentially serving as a non-invasive biomarker for the disease.

Emerging imaging and liquid biomarkers in multiple sclerosis

The advent of highly effective disease modifying therapy has transformed the landscape of multiple sclerosis (MS) care over the last two decades. However, there remains a critical, unmet need for sensitive and specific biomarkers to aid in diagnosis, prognosis, treatment monitoring, and the development of new interventions, particularly for people with progressive disease. This review evaluates the current data for several emerging imaging and liquid biomarkers in people with MS. MRI findings such as the central vein sign and paramagnetic rim lesions may improve MS diagnostic accuracy and evaluation of therapy efficacy in progressive disease. Serum and cerebrospinal fluid levels of several neuroglial proteins, such as neurofilament light chain and glial fibrillary acidic protein, show potential to be sensitive biomarkers of pathologic processes such as neuro-axonal injury or glial-inflammation. Additional promising biomarkers, including optical coherence tomography, cytokines and chemokines, microRNAs, and extracellular vesicles/exosomes, are also reviewed, among others. Beyond their potential integration into MS clinical care and interventional trials, several of these biomarkers may be informative of MS pathogenesis and help elucidate novel targets for treatment strategies.

Genetic Basis of Inflammatory Demyelinating Diseases of the Central Nervous System: Multiple Sclerosis and Neuromyelitis Optica Spectrum

Demyelinating diseases alter myelin or the coating surrounding most nerve fibers in the central and peripheral nervous systems. The grouping of human central nervous system demyelinating disorders today includes multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD) as distinct disease categories. Each disease is caused by a complex combination of genetic and environmental variables, many involving an autoimmune response. Even though these conditions are fundamentally similar, research into genetic factors, their unique clinical manifestations, and lesion pathology has helped with differential diagnosis and disease pathogenesis knowledge. This review aims to synthesize the genetic approaches that explain the differential susceptibility between these diseases, explore the overlapping clinical features, and pathological findings, discuss existing and emerging hypotheses on the etiology of demyelination, and assess recent pathogenicity studies and their implications for human demyelination. This review presents critical information from previous studies on the disease, which asks several questions to understand the gaps in research in this field.

Diet-related inflammation increases the odds of multiple sclerosis: Results from a large population-based prevalent case-control study in Jordan

Background

Multiple sclerosis, a chronic inflammatory disease in young and middle-aged adults, is one of the leading causes of non-traumatic disability in adults. Diet is known to have an important role in the modulating inflammatory processes and influencing molecular pathways.

Purpose

This study aims to examine the association of the inflammatory capacity of diet measured by DII with MS in Jordan.

Methods

This prevalent case-control study included participants of both sexes, aged between 20 and 60 years. The cases (n = 541) had a confirmed diagnosis of prevalent Multiple Sclerosis (MS) in the previous 3 years, and controls (n = 607) were apparently healthy individuals matched on sex and age (42 ± 4 years). A validated Arabic food frequency questionnaire (FFQ) was utilized to obtain estimated dietary intake. Dietary data from the FFQ were analyzed using ESHA's Food Processor® nutrition analysis software, and the results were used to calculate the DII scores. Logistic regression analyses, controlling for covariates such as age, sex, body mass index, and smoking status, were used to measure the association between DII score and MS outcomes.

Results

Cases represent a mixed sample of MS phenotypes and controls were comparable on age and sex. However, controls tended to be taller, lighter, had a lower BMI, and had a lower smoking rate. After controlling for age, BMI, sex, and smoking status, there was a consistent increase in MS risk according to DII score, with a 10-fold increase in odds in quartile 4 vs. quartile 1 [ORquartile 4vs1 = 10.17 (95% CI: 6.88; 15.04)]. For each point increase in DII score, there was nearly a doubling of odds [OR1 = 1.75 (95% CI: 1.59; 1.92)]. Individual nutrients and food values aligned according to their contribution to the DII score calculations.

Conclusion

The findings of this study, obtained in MS patients with varied illness duration over the previous 3 years, are consistent with an association between the overall inflammatory potential of diet and MS odds. Our findings among MS participants showed a significantly more pro-inflammatory DII scores than age- and sex-matched controls. Our results also suggest that MS group had a diet rich in pro-inflammatory foods and nutrients.

The role of SIRT1 level and SIRT1 gene polymorphisms in optic neuritis patients with multiple sclerosis

THE AIM

To investigate the role of Sirtuin 1 (SIRT1) level and SIRT1 (rs3818292, rs3758391, rs7895833) gene polymorphisms in patients with optic neuritis (ON) and multiple sclerosis (MS).

METHODS

79 patients with ON and 225 healthy subjects were included in the study. ON patients were divided into 2 subgroups: patients with MS (n = 30) and patients without MS (n = 43). 6 ON patients did not have sufficient data for MS diagnosis and were excluded from the subgroup analysis. DNA was extracted from peripheral blood leukocytes and genotyped by real-time polymerase chain reaction. Results were analysed using the program "IBM SPSS Statistics 27.0".

RESULTS

We discovered that SIRT1 rs3758391 was associated with a twofold increased odds of developing ON under the codominant (p = 0.007), dominant (p = 0.011), and over-dominant (p = 0.008) models. Also, it was associated with a threefold increased odds ofON with MS development under the dominant (p = 0.010), twofold increased odds under the over-dominant (p = 0.032) models and a 1.2-fold increased odds of ON with MS development (p = 0.015) under the additive model. We also discovered that the SIRT1 rs7895833 was significantly associated with a 2.5-fold increased odds of ON development under the codominant (p = 0.001), dominant (p = 0.006), and over-dominant (p < 0.001) models, and a fourfold increased odds of ON with MS development under the codominant (p < 0.001), dominant (p = 0.001), over-dominant (p < 0.001) models and with a twofold increased odds of ON with MS development (p = 0.013) under the additive genetic model. There was no association between SIRT1 levels and ON with/without MS development.

CONCLUSIONS

SIRT1 rs3758391 and rs7895833 polymorphisms are associated with ON and ON with MS development.

Changes in Gut Microbiota and Multiple Sclerosis: A Systematic Review

INTRODUCTION

Multiple sclerosis (MS) is a chronic inflammatory neurodegenerative disease mediated by autoimmune reactions against myelin proteins and gangliosides in the grey and white matter of the brain and spinal cord. It is considered one of the most common neurological diseases of non-traumatic origin in young people, especially in women. Recent studies point to a possible association between MS and gut microbiota. Intestinal dysbiosis has been observed, as well as an alteration of short-chain fatty acid-producing bacteria, although clinical data remain scarce and inconclusive.

OBJECTIVE

To conduct a systematic review on the relationship between gut microbiota and multiple sclerosis.

METHOD

The systematic review was conducted in the first quarter of 2022. The articles included were selected and compiled from different electronic databases: PubMed, Scopus, ScienceDirect, Proquest, Cochrane, and CINAHL. The keywords used in the search were: "multiple sclerosis", "gut microbiota", and "microbiome".

RESULTS

12 articles were selected for the systematic review. Among the studies that analysed alpha and beta diversity, only three found significant differences with respect to the control. In terms of taxonomy, the data are contradictory, but confirm an alteration of the microbiota marked by a decrease in Firmicutes, Lachnospiraceae, Bifidobacterium, Roseburia, Coprococcus, Butyricicoccus, Lachnospira, Dorea, Faecalibacterium, and Prevotella and an increase in Bacteroidetes, Akkermansia, Blautia, and Ruminocococcus. As for short-chain fatty acids, in general, a decrease in short-chain fatty acids, in particular butyrate, was observed.

CONCLUSIONS

Gut microbiota dysbiosis was found in multiple sclerosis patients compared to controls. Most of the altered bacteria are short-chain fatty acid (SCFA)-producing, which could explain the chronic inflammation that characterises this disease. Therefore, future studies should consider the characterisation and manipulation of the multiple sclerosis-associated microbiome as a focus of both diagnostic and therapeutic strategies.

Seasonal variations in vitamin D do not change the musculoskeletal health of physically active ambulatory men with cerebral palsy: a longitudinal cross-sectional comparison study

Increased levels of vitamin D in the summer months from natural seasonal variations in sun exposure have been linked to improvements in musculoskeletal health and function in UK populations; however, studies have shown that differences in lifestyles because of disability can inhibit the natural vitamin D increase in these populations. We hypothesized that men with cerebral palsy (CP) will experience smaller increases in 25-hydroxyvitamin D (25(OH)D) from winter to summer and men with CP will not experience any improvements in musculoskeletal health and function during the summer. A longitudinal observational study in 16 ambulant men with CP aged 21.0 ± 1.3 years and 16 healthy, physical activity matched, typically developed controls aged 25.4 ± 2.6 years, completed assessments of serum 25(OH)D and parathyroid hormone during winter and summer. Neuromuscular outcomes included vastus lateralis size, knee extensor strength, 10-m sprint, vertical jumps, and grip strength. Bone ultrasounds were performed to obtain radius and tibia T and Z scores. Men with CP and typically developed controls showed a 70.5% and 85.7% increase in serum 25(OH)D from winter to summer months, respectively. Neither group showed seasonal effect on neuromuscular outcomes muscle strength, size, vertical jump, or tibia and radius T and Z scores. A seasonal interaction effect was seen in the tibia T and Z scores (P < .05). In conclusion, there were similar seasonal increases in 25(OH)D observed in men with CP and typically developed controls, but serum 25(OH)D levels were still considered insufficient to improve bone or neuromuscular outcomes.

Gut-Microbiota, and Multiple Sclerosis: Background, Evidence, and Perspectives

Many scientific studies reveal a significant connection between human intestinal microbiota, eating habits, and the development of chronic-degenerative diseases; therefore, alterations in the composition and function of the microbiota may be accompanied by different chronic inflammatory mechanisms. Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS), in which autoreactive immune cells attack the myelin sheaths of the neurons. The purpose of this paper was to describe the main changes that occur in the gut microbiota of MS patients, with a focus on both microbiota and its implications for health and disease, as well as the variables that influence it. Another point stressed by this paper is the role of microbiota as a triggering factor to modulate the responses of the innate and adaptive immune systems, both in the intestine and in the brain. In addition, a comprehensive overview of the taxa modified by the disease is presented, with some points on microbiota modulation as a therapeutic approach for MS. Finally, the significance of gastro-intestinal pains (indirectly related to dysbiosis) was assessed using a case study (questionnaire for MS patients), as was the willingness of MS patients to modulate gut microbiota with probiotics.

Baseline Gait and Motor Function Predict Long-Term Severity of Neurological Outcomes of Viral Infection

Neurological dysfunction following viral infection varies among individuals, largely due to differences in their genetic backgrounds. Gait patterns, which can be evaluated using measures of coordination, balance, posture, muscle function, step-to-step variability, and other factors, are also influenced by genetic background. Accordingly, to some extent gait can be characteristic of an individual, even prior to changes in neurological function. Because neuromuscular aspects of gait are under a certain degree of genetic control, the hypothesis tested was that gait parameters could be predictive of neuromuscular dysfunction following viral infection. The Collaborative Cross (CC) mouse resource was utilized to model genetically diverse populations and the DigiGait treadmill system used to provide quantitative and objective measurements of 131 gait parameters in 142 mice from 23 CC and SJL/J strains. DigiGait measurements were taken prior to infection with the neurotropic virus Theiler's Murine Encephalomyelitis Virus (TMEV). Neurological phenotypes were recorded over 90 days post-infection (d.p.i.), and the cumulative frequency of the observation of these phenotypes was statistically associated with discrete baseline DigiGait measurements. These associations represented spatial and postural aspects of gait influenced by the 90 d.p.i. phenotype score. Furthermore, associations were found between these gait parameters with sex and outcomes considered to show resistance, resilience, or susceptibility to severe neurological symptoms after long-term infection. For example, higher pre-infection measurement values for the Paw Drag parameter corresponded with greater disease severity at 90 d.p.i. Quantitative trait loci significantly associated with these DigiGait parameters revealed potential relationships between 28 differentially expressed genes (DEGs) and different aspects of gait influenced by viral infection. Thus, these potential candidate genes and genetic variations may be predictive of long-term neurological dysfunction. Overall, these findings demonstrate the predictive/prognostic value of quantitative and objective pre-infection DigiGait measurements for viral-induced neuromuscular dysfunction.

Ultra-processed foods consumption is associated with multiple sclerosis severity

Background

MS is a chronic inflammatory neurological and immune-mediated disease of multifactorial etiology. Ultra-processed foods (UPFs) have been generally considered unhealthy due to their poor nutritional value. Emerging evidence suggests that factors other than their nutritional content may play an additional role toward chronic inflammation.

Aim

To investigate the potential association of UPF consumption and MS severity in a group of MS Italian consecutive patients.

Methods

Demographic (age, sex, marital status, educational level), neurological (EDSS, MSSS), and nutritional (anthropometric measures, dietary habits) information were collected. Physical activity and smoking habits were also investigated. Food items were grouped according to the NOVA classification. Patients were classified in two groups based on MS severity ("mild" and "moderate to high").

Results

Higher UPF consumption was associated with moderate-to-high MS severity compared to lower consumption in both the unadjusted model (OR = 2.28, 95% CI: 1.04-5.01) and after adjustment for potential background (OR = 2.46, 95% CI: 1.04-5.83) and clinical confounding factors (OR = 2.97, 95% CI: 1.13-7.77).

Conclusions

Although these results are only preliminary and hypothesis generating, it is important to explore how various aspects of the diet may relate to MS severity in order to identify the best strategy to support MS patients over the disease course.

Synapse Dysfunctions in Multiple Sclerosis

Multiple sclerosis (MS) is a chronic neuroinflammatory disease of the central nervous system (CNS) affecting nearly three million humans worldwide. In MS, cells of an auto-reactive immune system invade the brain and cause neuroinflammation. Neuroinflammation triggers a complex, multi-faceted harmful process not only in the white matter but also in the grey matter of the brain. In the grey matter, neuroinflammation causes synapse dysfunctions. Synapse dysfunctions in MS occur early and independent from white matter demyelination and are likely correlates of cognitive and mental symptoms in MS. Disturbed synapse/glia interactions and elevated neuroinflammatory signals play a central role. Glutamatergic excitotoxic synapse damage emerges as a major mechanism. We review synapse/glia communication under normal conditions and summarize how this communication becomes malfunctional during neuroinflammation in MS. We discuss mechanisms of how disturbed glia/synapse communication can lead to synapse dysfunctions, signaling dysbalance, and neurodegeneration in MS.

An Overview of the History, Pathophysiology, and Pharmacological Interventions of Multiple Sclerosis

Multiple sclerosis (MS) is an immune-inflammatory disease that attacks and damages myelinated axons in the central nervous system (CNS) and causes nontraumatic neurological impairment in young people. Historically, Lidwina of Schiedam documented the first MS case. After that, Augustus d'Este wrote for years about how his MS symptoms worsened. Age, sex, genetics, environment, smoking, injuries, and infections, including herpes simplex and rabies, are risk factors for MS. According to epidemiology, the average age of onset is between 20 and 40 years. MS is more prevalent in women and is common in Europe and America. As diagnostic methods and criteria change, people with MS may be discovered at earlier and earlier stages of the disease. MS therapy has advanced dramatically due to breakthroughs in our knowledge of the disease's etiology and progression. Therefore, the efficacy and risk of treatment medications increased exponentially. Management goals include reducing lesion activity and avoiding secondary progression. Current treatment approaches focus on managing acute episodes, relieving symptoms, and reducing biological activity. Disease-modifying drugs such as fingolimod, interferon-beta, natalizumab, and dimethyl fumarate are the most widely used treatments for MS. For proof of the efficacy and safety of these medications, investigations in the real world are necessary.

Trends in the environmental risks associated with earlier onset in multiple sclerosis

BACKGROUND

Several environmental and lifestyle factors relating to sunlight/vitamin D, body mass index (BMI), and smoking are associated with the risk of developing multiple sclerosis (MS). However, their relation to disease progression, particularly age at symptomatic onset, remains inconsistent, which may be the result of significant changes in human-environment interactions over the last century. This study investigates historical trends in the association between common MS environmental risk factors and age at disease onset.

METHODS

Using a narrative approach, we evaluated the current literature for published studies assessing the association between vitamin-D, BMI, and tobacco smoking exposures with the risk of early/pediatric-onset MS and direct correlations with age at MS onset using MEDLINE, EMBASE, and Web of Science. Measures were plotted by the average calendar year of disease onset for each cohort to examine trends over time. In total, 25, 9, and 11 articles were identified for vitamin D, BMI, and smoking-related exposures, respectively.

RESULTS

Higher sun exposure habits and residential solar radiation were associated with older age at onset. On the contrary, two studies observed a negative correlation between age at onset and serum 25-hydroxyvitamin D (25(OH)D) levels. Higher adolescent BMI was generally associated with younger age at onset, although genetic susceptibility for childhood obesity was not significantly associated. Tobacco smoking was associated with later disease onset, despite being a risk factor for MS. Association with age at onset was inflated for more recent studies relating to smoking, while often weaker for serum vitamin D and BMI.

CONCLUSION

Current findings indicate a likely association between age at onset and environmental risk factors, such as sun exposure, adolescent BMI, and tobacco smoking, in certain populations. However, findings are often inconsistent and assessment of the relationships and potential changes over time require further investigation.

Epstein-Barr virus antibody in newly diagnosed multiple sclerosis patients and its association with relapse severity and lesion location

BACKGROUND

Epstein-Barr virus is considered a risk factor for the development of multiple sclerosis, and recent findings reveal infected plasma -cells in meningeal ectopic lymphoid deposits. Activation of the dormant virus could be responsible for the multiple sclerosis exacerbation AIMS: To compare Epstein-Barr nuclear IgG (EBNA IgG) titer in newly diagnosed treatment-naive multiple sclerosis patients regarding the diagnoses date, clinical and radiological activity.

METHODS

Treatment-naive multiple sclerosis patients were divided into two groups according to Poser (late group) and McDonald2017(early group) diagnostic criteria. EBNA IgG, EDSS, physical (Timed 25 Foot Walk test, Nine-hole Peg test), and cognitive tests (Brief International Cognitive Assessment for Multiple Sclerosis) were done before the methylprednisolone infusion. The lesion location was evaluated by an MRI. Myelitis was considered a severe attack, and optic neuritis a mild relapse.

RESULTS

In total, 69 patients were enrolled. 44 (63.8%) of them were diagnosed by McDonald2017, and 25 (36.2%) were diagnosed with Poser criteria. There was a significant difference (p = 0.049) between the EBNA IgG titer of the late (median:238 U/ml, IQR: 154-362) and early (median: 154 U/ml, IQR:100.25-293.25). Severe relapse, having a spinal cord lesion, and not being treated with methylprednisolone was associated with higher EBNA IgG titer.

CONCLUSION

Study results show that EBNA IgG was significantly associated with disease activity regarding relapse severity and lesion location and could be a potential biomarker for predicting disease exacerbation.

The Role of the Thioredoxin System in Brain Diseases

The thioredoxin system, consisting of thioredoxin (Trx), thioredoxin reductase (TrxR), and NADPH, plays a fundamental role in the control of antioxidant defenses, cell proliferation, redox states, and apoptosis. Aberrations in the Trx system may lead to increased oxidative stress toxicity and neurodegenerative processes. This study reviews the role of the Trx system in the pathophysiology and treatment of Alzheimer's, Parkinson's and Huntington's diseases, brain stroke, and multiple sclerosis. Trx system plays an important role in the pathophysiology of those disorders via multiple interactions through oxidative stress, apoptotic, neuro-immune, and pro-survival pathways. Multiple aberrations in Trx and TrxR systems related to other redox systems and their multiple reciprocal relationships with the neurodegenerative, neuro-inflammatory, and neuro-oxidative pathways are here analyzed. Genetic and environmental factors (nutrition, metals, and toxins) may impact the function of the Trx system, thereby contributing to neuropsychiatric disease. Aberrations in the Trx and TrxR systems could be a promising drug target to prevent and treat neurodegenerative, neuro-inflammatory, neuro-oxidative stress processes, and related brain disorders.

Body Composition in Multiple Sclerosis Patients and Its Relationship to the Disability Level, Disease Duration and Glucocorticoid Therapy

Background: Patients with multiple sclerosis (MS) have many potential factors (spasticity, immobilization, glucocorticoids use) for the deterioration of body composition. Aim: To assess the nutritional status (by classical anthropometry and by bioelectrical impedance analysis (BIA)) in MS patients and to correlate it with clinical state, MS duration time and the presence of glucocorticoid therapy in anamnesis (ever used). Methods: Anthropometrical (BMI and waist and hip circumferences, waist-to-height ratio (W/HtR), and waist-to-hip ratio (WHR)) and body composition (BIA) data were evaluated in 176 patients with MS. Fat mass (FM), and fat-free mass (FFM) were expressed as kilograms (kg), percentage (%) and indexes (FMI: fat mass index, FFMI: fat-free mass index) expressed in kg/m2. The median Expanded Disability Status Scale score was 4.5. Patients were then divided according to EDSS score as mild (EDSS 1.0−4.0) or moderate (EDSS 4.5−6.5) disability subgroup. Results: Waist c., WHtR, WHR, and FM% were significantly higher in the moderate MS group (p < 0.01; p < 0.001; p < 0.001; and p < 0.05, respectively). Whilst, FFM% was significantly lower (p < 0.05). BMI did not correlate significantly with any disability status score and MS time. Significant correlations were observed between EDSS, ΔEDSS and MS time and Waist c., WHtR, WHR, FM% and FFM%. WHtR had the strongest significance (p < 0.0001 vs. EDSS; p < 0.0001 vs. ΔEDSS; and p < 0.01 vs. MS time, respectively). After the adjustment to the MS time, only FM% was no longer significantly related to both EDSS and ΔEDSS. MS duration time, EDSS, ΔEDSS, WHtR, FM(kg), FM%, and FMI were significantly higher in the patients with a positive history of glucocorticoid therapy (all p < 0.05). Whilst, FFM% was significantly lower in MS patients treated with glucocorticoids (p < 0.01). Conclusions: Greater disability in MS patients is strongly related to lower fat-free mass and higher fat mass, especially with the abdominal distribution, irrespective of the duration time of the disease. Oral glucocorticoid therapy seems to have a negative impact on the body composition of MS patients. However, further prospective multifactorial studies in this field have to be done. For the proper assessment of nutritional status in MS patients, Waist c., WHtR, WHR, or body composition parameters seem to be of greater use than BMI.

Clinical and Genetic Analysis in Pediatric Patients with Multiple Sclerosis and Related Conditions: Focus on DR Genes of the Major Histocompatibility Complex

Introduction:

There are several diseases recognized as variants of MS: post-infectious acute disseminated encephalitis, multiple sclerosis (MS), Rasmussen leukoencephalitis and Schilder's leukoencephalitis and related, but separate neuroimmune condition – Neuromyelitis Devic’s. In Kazakhstan diagnosis of such diseases was rare and immune modified treatment was only admitted after the age of 18. Clinical and immunogenetic study of MS spectrum diseases in Kazakhstan would allow to justify early targeted treatment.

Objective:

The aim of the study was to investigate genes of the main complex of human histocompatibility (MHC) associated with diseases of MS spectrum in Kazakhstani population.

Methods:

Complex clinical, neuroimaging and immunogenetic studies were performed in 34 children (24 girls, 10 boys) aged 4 to 18 years. 21 children were diagnosed with MS (11 Kazakh origin and 10 – Russian; 4 boys, 17 girls), 7 with leucoencephalitis (all Kazakh, 5 boys, 2 girls) and 6 with Devic neuromyelitis optica (all Kazakh, 1 boy, 5 girls). Genotyping of HLA DRB1, DQA1, DQB1 genes was performed for all patients.

Results:

MS group was characterized by classical relapsing-remitting MS. Predominant haplotype as a linkage complex was DRB1*15:01~DQA1*01:02~DQB1*06:02 in 20 (47.6%) of 42 DR-alleles, in 16 (76.2%) patients. MS relative risk (RR) was 13,36 for ethnic Kazakhs and RR=5,55 in Russians.

Leukoencephalitis had 7 children, with 28.6% mortality rate. The haplotype DRB1*15:01~DQA1*01:02~DQB1*06:02 as a linkage complex was detected 3 patients (4 alleles), RR=5,88.

Devic’s neuromyelitis optica (NMO) clinical course was characterized by fast and prolonged progression. There was predominance of DRB1*14 allele with RR=3,38.

Conclusion:

Summarizing, in the Kazakh population the haplotype DRB1*15:01∼DQA1*01:02∼DQB1*06:02 as a linkage complex was associated with prediction to MS and leukoencephalitis, but not to Devic’s NMO. Our study highlights the importance of awareness of MS and related disorders diagnosis which allows to implement early admission of disease-modified treatment in pediatric MS in Kazakhstan.

High Correlations Among Worldwide Prevalences of Dementias, Parkinson's Disease, Multiple Sclerosis, and Motor Neuron Diseases Indicate Common Causative Factors

Dementia, Parkinson's disease, multiple sclerosis, and motor neuron diseases cause significant disability and mortality worldwide. Although the etiology of these diseases is unknown, highly correlated disease prevalences would indicate the involvement of common etiologic factors. Here we used published epidemiological data in 195 countries worldwide to investigate the possible intercorrelations among the prevalences of these diseases. All analyses were carried out using nonparametric statistics on rank-transformed data to assure the robustness of the results. We found that all 6 pairwise correlations among the prevalences of the 4 diseases were very high (>.9, P < .001). A factor analysis (FA) yielded only a single component which comprised all 4 disease prevalences and explained 96.3% of the variance. These findings indicate common etiologic factor(s). Next, we quantified the contribution of 3 country-specific factors (population size, life expectancy, latitude) to the common grouping of prevalences by estimating the reduction in total FA variance explained when the effect of these factors was eliminated by using the prevalence residuals from a linear regression where theses factor were covariates. FA of these residuals yielded again only a single component comprising all 4 diseases which explained 71.5% of the variance, indicating that the combined contribution of population size, life expectancy and latitude accounted for 96.3% - 71.5% = 24.8% of the FA variance explained. The fact that the 3 country-specific factors above accounted for only 24.8% of the FA variance explained by the original (ranked) disease prevalences, in the presence still of a single grouping factor, strongly indicates the operation of other unknown factors jointly contributing to the pathogenesis of the 4 diseases. We discuss various possible factors involved, with an emphasis on biologic pathogens (viruses, bacteria) which have been implicated in the pathogenesis of these diseases in previous studies.

Beyond the CAG triplet number: exploring potential predictors of delayed age of onset in Huntington's disease

OBJECTIVE

Huntington's disease (HD) is a genetic neurodegenerative disease characterized by cognitive, motor, and psychiatric dysfunction. It is caused by an expansion of the trinucleotide repeat sequence cytosine-adenine-guanine (CAG) in the Huntingtin gene on chromosome 4. Onset typically occurs in the fourth or fifth decade, ranging from childhood to late adulthood. The CAG triplet number is generally inversely proportional to the age of onset (AOO), but the repeat number only accounts for ∼70% of the variability in AOO. Several studies demonstrated the impact of genetic modifiers on age of disease onset. In addition to genetics, we also explored the demographic, anamnestic, and socio-environmental factors that can affect AOO, to help us understand the non-genetic variability of age of onset in HD.

METHODS

We analyzed the retrospective data of the ENROLL-HD global registry study, particularly focusing on the continuum of ages, to include sociodemographic, genetic, and anamnestic psychobehavioral variables in a multivariate regression model aimed at identifying the potential predictors of age of motor onset (n = 5053). We ran the same regression model in the sample of subjects who had the same number of triplets (41 CAG, n = 593) and in the sample whose family history was absent/unknown (n = 630).

RESULTS

Patients with delayed onset more frequently have unknown/missing family history, are married or widowed, live in larger urbanized contexts and have a lower educational level. Individuals with earlier onset more frequently develop psychobehavioral symptoms.

CONCLUSIONS

In the past, the HD gene was considered the epitome of genetic determinism. Our results are consistent with recent evidence that other factors might modulate its impact. These findings allow characterizing the determinants of AOO beyond the CAG expansions and provide valuable information for stratifying patients for future clinical trial designs.

EATİNG ATTİTUDE İN MULTİPLE SCLEROSİS

Aim: To examine attitudes to eating in multiple sclerosis (MS) patients. Material and Method: The study included 64 cases diagnosed with MS according to the 2017 McDonald criteria and a control group of 64 healthy volunteers of similar age, gender, and education level. All the study participants underwent a detailed neurological examination and were then administered the Eating Attitudes Test (EAT), the Beck Anxiety Inventory (BAI), and the Beck Depreession Inventory (BDI). Results: In the comparisons between the groups of the EAT results, a score of ≥30 was obtained by 24 (37.5%) MS patients and 14 (21.8%) of the control group. When the MS patients were compared in two groups according to the Expanded Disability Status Scale (EDSS) score of ≤3 and ≥4, an EAT score of ≥30 was obtained by 11 (25%) patients with EDSS score ≤ 3 and by 13 (68.5%) patients with EDSS ≥4. Conclusion:The study results demonstrated that the patients with MS had a worse attitude to eating than the control subjects. When it is considered that some foodstuffs are among MS triggers, the presence of eating disorders or poor eating behaviour becomes important.

FutureMS cohort profile: a Scottish multicentre inception cohort study of relapsing-remitting multiple sclerosis

PURPOSE

Multiple sclerosis (MS) is an immune-mediated, neuroinflammatory disease of the central nervous system and in industrialised countries is the most common cause of progressive neurological disability in working age persons. While treatable, there is substantial interindividual heterogeneity in disease activity and response to treatment. Currently, the ability to predict at diagnosis who will have a benign, intermediate or aggressive disease course is very limited. There is, therefore, a need for integrated predictive tools to inform individualised treatment decision making.

PARTICIPANTS

Established with the aim of addressing this need for individualised predictive tools, FutureMS is a nationally representative, prospective observational cohort study of 440 adults with a new diagnosis of relapsing-remitting MS living in Scotland at the time of diagnosis between May 2016 and March 2019.

FINDINGS TO DATE

The study aims to explore the pathobiology and determinants of disease heterogeneity in MS and combines detailed clinical phenotyping with imaging, genetic and biomarker metrics of disease activity and progression. Recruitment, baseline assessment and follow-up at year 1 is complete. Here, we describe the cohort design and present a profile of the participants at baseline and 1 year of follow-up.

FUTURE PLANS

A third follow-up wave for the cohort has recently begun at 5 years after first visit and a further wave of follow-up is funded for year 10. Longer-term follow-up is anticipated thereafter.

Therapeutic Role of Vitamin D in Multiple Sclerosis: An Essentially Contested Concept

Multiple sclerosis (MS) is an immune-mediated demyelinating disease of the nervous system with incredibly intricate etiopathogenesis involving numerous genetic, epigenetic, and environmental risk factors. Major environmental risk factors include ultraviolet (UV) radiation, vitamin D, Epstein-Barr virus (EBV) infection, smoking, and high body mass index (BMI). Vitamin D, in particular, can be viewed as one piece of this puzzle, with various tabs and pockets, occupying a sequential site. In this article, we have briefly discussed the neuroimmunology of MS and the role of vitamin D in regulating immune responses. Various observational studies and clinical trials were reviewed and discussed according to stages of disease activity and course of the disease. The data reviewed in this article implied that serum vitamin D levels greatly influence the risk of developing MS and disease activity. Long-term follow-up studies indicated that low serum vitamin D levels correlate with worse disability outcomes. Since clinical trials did not provide significant evidence, the role of vitamin D in controlling disease activity remains unresolved. Larger clinical trials are needed to support the findings of observational studies and provide significant evidence in favour of vitamin D. 

Bilateral cranial nerve 6 palsy in a patient with multiple sclerosis and vitamin D-dependent rickets

The development of multiple sclerosis (MS) is multifactorial. Elevated levels of vitamin D may lower the risk and reduce relapses by immunomodulatory mechanisms. Conversely, vitamin D-dependent rickets (VDDR), an inheritable form of rickets secondary to impairment in vitamin D synthesis or action, may increase MS risk. This has been described in three patients with VDDR type 1A. Here, we present a patient with VDDR type 2 - unclear if type 2A or 2B based on historical genetic testing - who subsequently developed MS. She presented with 8 weeks of binocular horizontal diplopia and was found to have 8 prism dioptres of esotropia in primary gaze and a mild limitation of abduction in both eyes. Radiological workup was consistent with MS demyelination. She was started on solumedrol infusions, with full resolution of the esotropia and abduction deficits. She has since been transitioned to ocrelizumab with vitamin D supplementation and has not had a relapse to date. It is important to consider MS in patients genetically predisposed to low vitamin D levels or functional impairment, as with VDDR. Vitamin D supplementation can achieve remission in some forms of VDDR, and its role in MS prevention in these patients should be considered. In patients with type 2A or 2B VDDR, who have impairment in receptor function, additional treatment modalities require investigation. Lastly, demyelination is a rare cause of bilateral cranial nerve 6 palsy. This case illustrates the importance of considering MS in cranial nerve palsies, particularly in patients with vitamin D deficiencies or functional impairment.

The analysis of dynamic gene expression patterns in peripheral blood of multiple sclerosis patients indicates possible diagnostic and prognostic biomarkers

INTRODUCTION

Among numerous invasive procedures for the research of biomarkers, blood-based indicators are regarded as marginally non-invasive procedures in the diagnosis and prognosis of demyelinating disorders, including multiple sclerosis (MS). In this study, we looked into the blood-derived gene expression profiles of patients with multiple sclerosis to investigate their clinical traits and linked them with dysregulated gene expressions to establish diagnostic and prognostic indicators.

METHODS

We included 51 patients with relapsing-remitting MS (RRMS, n = 31), clinically isolated syndrome (CIS, n = 12), primary progressive MS (PPMS, n = 8) and a control group (n = 51). Using correlational analysis, the transcriptional patterns of chosen gene panels were examined and subsequently related with disease duration and the expanded disease disability score (EDSS). In addition, principal component analysis, univariate regression, and logistic regression analysis were employed to highlight distinct profiles of genes and prognosticate the excellent biomarkers of this illness.

RESULTS

Our findings demonstrated that neurofilament light (NEFL), tumor necrosis factor α (TNF-α), Tau, and clusterin (CLU) were revealed to be increased in recruited patients, whereas the presenilin-1 (PSEN1) and cell-surface glycoprotein-44 (CD44) were downregulated. Principal Component Analysis revealed distinct patterns between the MS and control groups. Correlation analysis indicated co-dependent dysregulated genes and their differential expression with clinical findings. Furthermore, logistic regression demonstrated that Clusterin (AUC=0.940), NEFL (AUC=0.775), TNF-α (AUC=0.817), Tau (AUC=0.749), PSEN1 (AUC=0.6913), and CD44 (AUC=0.832) had diagnostic relevance. Following the univariate linear regression, a significant regression equation was found between EDSS and IGF-1 (R² adj = 0.10844; p= 0.0060), APP (R² adj = 0.1107; p= 0.0098), and PSEN1 (R² adj = 0.1266; p=0.0102).

CONCLUSION

This study exhibits dynamic gene expression patterns that represent the significance of specified genes that are prospective diagnostic and prognostic biomarkers for multiple sclerosis.

Rare co-occurrence of multiple sclerosis and Wilson's disease - case report

Background

Wilson’s disease is a hereditary disorder of copper metabolism resulting mainly in hepatic, neurological, and psychiatric symptoms. Multiple sclerosis (MS) is an immune-mediated demyelinating disease affecting the central nervous system (CNS). The co-occurrence of these two, although not unheard of in literature, is still considered to be very rare and can give rise to diagnostic difficulties. Also, comorbidity in MS highly influences quality of life and disease progression, which makes the timely diagnosis and treatment of these conditions essential.

Case presentation

The aim of this study is to present a patient exhibiting symptoms of both MS and Wilson’s disease, as well as to conduct a detailed review of previously reported cases. The patient’s neurological symptoms (sensory disorder) as well as MRI and CSF findings were characteristic for MS. The diagnosis of MS preceded that of Wilson’s disease and was relatively mild in course. Currently, the patient receives cladribine as an immunomodulatory treatment after escalation from glatiramer acetate therapy. Apart from one episode of acute hepatic decompensation, during which transfusion, albumin supplementation and diuretic treatment was necessary, Wilson’s disease manifested as chronic impairment of liver function. The diagnosis of Wilson’s disease was established by the analysis of serum coeruloplasmin levels, histological examination and genetic findings. Continuous oral penicillamine therapy led to the slow normalization of hepatic function and significant amelioration of the patient’s symptoms. Correlating with cases previously reported, the course of MS was relatively mild, and like in three out of four other known cases, the symptoms of Wilson’s disease were mostly restricted to hepatic dysfunction.

Conclusion

The case presented in our report is similar to those reported before. The co-occurrence of the two diseases seems to be more a coincidence than a sharing of common factors in their pathogenesis; however, they are considered to influence one another. Regarding rare co-occurrences such as this one, every new case is of high importance, as it enables a better evaluation and understanding of the clinical presentations that are more characteristic of these cases, thus aiding the estimation of disease course as well as possible therapeutic choices.

Synthesis and biological evaluation of artemisinin derivatives as potential MS agents

In this paper, a series of artemisinin derivatives were synthesized and evaluated. Studies have shown that IFN-γ produced by Th1 CD4⁺ T cells and IL-17A secreted by Th17 CD4⁺ T cells played critical roles in the treatment of multiple sclerosis. We used different concentrations of artemisinin derivatives to inhibit Th1 / Th17 differentiation in naive CD4⁺ T cells and to characterize IFN-γ / IL-17A in in vitro experiments. The preliminary screening results showed that ester compound 5 exhibited obvious inhibitory activities on Th1 and Th17 (IFN-γ decreased from 41% to 3% and IL-17A decreased from 24% to 8% at the concentration of 10 nM to 10 μM), and carbamate compounds also had obvious inhibitory activities against Th17 at high concentration. Moreover, we investigated the effect of compound 5 on myelin oligodendrocyte glycoprotein (MOG)-induced mice experimental autoimmune encephalomyelitis (EAE) model in vivo. 100 mg/kg compound 5 effectively reduced the disease severity of EAE compared with the vehicle group. This research revealed that compound 5 could be a promising avenue as potential MS inhibitor.

Total Dairy Consumption Is Not Associated With Likelihood of a First Clinical Diagnosis of Central Nervous System Demyelination

Background

The evidence associating consumption of dairy products and risk of MS is contradictory and inconclusive.

Objective

To test associations between dairy consumption and the likelihood of a first clinical diagnosis of central nervous system demyelination (FCD), a common precursor to MS.

Methods

We used data from the 2003–2006 Ausimmune Study, a population-based Australian, multicentre, matched case-control study (272 cases, 519 controls). Total dairy consumption (servings/day) was calculated by summing consumption of milk, cheese and yogurt. Covariate-adjusted treatment effects using augmented inverse probability weighting was used to test for associations with FCD. We conducted sensitivity analyses in the subset of participants who had had a classic first demyelinating event (FDE), defined as a single, first episode of symptoms suggestive of CNS demyelination.

Results

There were no statistically significant associations between total dairy consumption (per one serving/day) and FCD (adjusted OR 1.00; 95% CI 0.93, 1.07; p = 0.979). However, yogurt consumption (vs. no yogurt consumption) was associated with an 11% decreased likelihood of FDE (adjusted OR 0.89; 95% CI 0.89, 0.79; p = 0.046).

Conclusion

While total dairy consumption was not associated with FCD in this Australian case-control study, yogurt consumption was associated with reduced likelihood of FDE.

Adherence to healthy dietary pattern is associated with lower risk of multiple sclerosis

Background

Different studies have confirmed the role of nutritional factors in the etiology of Multiple sclerosis (MS). However, dietary patterns associated with the risk of MS remain unknown.

Objectives

This study aimed to investigate the possible relationship between the existing dietary patterns and the risk of MS.

Methods

This case-control study was conducted in Mashhad city, Iran in 2015. In total, 197 MS patients and 200 control subjects (matched in terms of age, gender, education level, and body mass index) were enrolled in this study. The required data were collected through interviews and questionnaire completion. Moreover, the data on the usual dietary intake of each participant during the past year were evaluated using a valid and reliable semi-quantitative food frequency questionnaire (160 items). Logistic regression analysis was applied to discover the associations between dietary patterns and the risk of MS.

Results

Four major dietary patterns were identified in this study, including Unhealthy, Western, Healthy, and Traditional. After adjustment for smoking habits, the family history of autoimmune diseases and the duration of breastfeeding, the highest tertile of Healthy dietary pattern was found to be associated with the reduced risk of MS by 74% (OR = .26; P < .001), whereas the Unhealthy dietary pattern was associated with a three-fold increased risk of MS (OR = 3.04; P < .001). However, no correlation was observed between the Western and Traditional dietary patterns and the risk of MS.

Conclusion

According to the results of this study, a healthy diet may reduce the risk of MS, whereas an unhealthy dietary pattern may.

Investigating the disordered regions (MoRFs, SLiMs and LCRs) and functions of mimicry proteins/peptides in silico

Microbial mimicry of the host proteins/peptides can elicit host auto-reactive T- or B-cells resulting in autoimmune disease(s). Since intrinsically disordered protein regions (IDPRs) are involved in several host cell signaling and PPI networks, molecular mimicry of the IDPRs can help the pathogens in substituting their own proteins in the host cell-signaling and PPI networks and, ultimately hijacking the host cellular machinery. Thus, the present study was conducted to discern the structural disorder and intrinsically disordered protein regions (IDPRs) like, molecular recognition features (MoRFs), short linear motifs (SLiMs), and low complexity regions (LCRs) in the experimentally verified mimicry proteins and peptides (mimitopes) of bacteria, viruses and host. Also, functional characteristics of the mimicry proteins were studied in silico. Our results indicated that 78% of the bacterial host mimicry proteins and 45% of the bacterial host mimitopes were moderately/highly disordered while, 73% of the viral host mimicry proteins and 31% of the viral host mimitopes were moderately/highly disordered. Among the pathogens, 27% of the bacterial mimicry proteins and 13% of the bacterial mimitopes were moderately/highly disordered while, 53% of the viral mimicry proteins and 21% of the viral mimitopes were moderately/highly disordered. Though IDPR were frequent in host, bacterial and viral mimicry proteins, only a few mimitopes overlapped with the IDPRs like, MoRFs, SLiMs and LCRs. This suggests that most of the microbes cannot use molecular mimicry to modulate the host PPIs and hijack the host cell machinery. Functional analyses indicated that most of the pathogens exhibited mimicry with the host proteins involved in ion binding and signaling pathways. This is the first report on the disordered regions and functional aspects of experimentally proven host and microbial mimicry proteins.

Prevention of MS Requires Intervention on the Causes of the Disease: Reconciling Genes, Epigenetics, and Epstein Barr Virus

Prevention of multiple sclerosis requires intervention on modifiable causes of the condition making it necessary to establish what those causes are. MS is often stated to be a polygenic disease, with causal contributions from environmental factors and gene-environment interactions, implying an additive and independent relationship of these factors. Mechanistically there are no independent contributions of genes or environmental factors to traits. This model is unrealistic but still useful and underlies the concept of heritability, a foundational parameter in population genetics. However, it perpetuates a debate on an irreconcilable dichotomy about whether MS is primarily genetic or environmental. In particular, epidemiological evidence now exists for a causal, possibly even necessary, role for Epstein Barr Virus in MS. The additive model makes it unintuitive to reconcile MS as a genetic disease but also independently a viral illness. In this perspective it is argued that starting from a realistic interaction only model, based on broadly accepted biological premises, and working forward to explain why the classical additive model gives useful results, there is actually no paradox. An integrated approach using population genetic studies, immunology and molecular virology offers a particularly promising route to establish the elusive role of EBV in MS pathology, as EBV is a large and complex virus and its latency, dysregulated in most EBV-related pathologies, is hard to study in vivo. This approach may offer a route to prevention of MS altogether.

Antimuscarinics for neurogenic overactive bladder in multiple sclerosis: real-life data

Background:

Antimuscarinics (AMs) represent the mainstay of treatment for storage lower urinary tract symptoms (LUTS) but few data are available on their impact in multiple sclerosis (MS) patients.

Objective:

To assess effectiveness and tolerability of AMs in MS patients with neurogenic detrusor overactivity (NDO).

Methods:

Sixty consecutive outpatients, who started treatment with AMs at one centre, were recruited. The primary endpoint was change in Patient’s Perception of Intensity of Urgency Scale (PPIUS) at 6 months; secondary endpoints were post-void residual urine (PVR) and pads used daily. Incidence and severity of adverse events (AEs) were recorded.

Results:

Significant reduction (p < 0.001) of mean PPIUS and pads use were detected, as well as a significant increase (p < 0.001) of PVR (143 ± 42 ml).

AEs, recorded in 53% of patients, were frequently multiple and caused suspension of AM in 10% of cases, mainly for xerostomia, which has been the commonest AE (26.6%). Neurological AEs appeared in 11.7% of subjects, mostly with oxybutynin. Worsening/onset of voiding LUTS, reported by 8.3% of MS, resulted to be the unique AE correlated to AM dosage.

Conclusion:

This study suggests that AMs are effective in MS patients, but their use should be tailored on every patient as even low dosages can be poorly tolerated. AEs, including neurological ones, are common.